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Editor,—We read with interest the paper by Gweeet al (Gut1999;44:400–406) which described the role of psychological and biological factors in postinfective irritable bowel syndrome (IBS). However, these authors did not study fructose or lactose malabsorption in relation to duodenal function. Carbohydrate malabsorption syndromes—for example, fructose and/or lactose malabsorption, are frequently linked to IBS.1 Patients with fructose malabsorption often have a clear history of postinfective onset of their symptoms, as Gwee and colleagues found in patients with IBS.
We have shown an association between carbohydrate malabsorption syndromes and early signs of mental depression2 3; similarly, Gwee et al found significant links between anxiety, depression, and somatisation scores in patients with IBS. Our data suggest that non-absorbed carbohydrates interfere with tryptophan metabolism, which may explain the development of anxiety, mental depression, and other signs of serotonin deficiency.4 Furthermore, most of our patients were diagnosed as having IBS before a diagnosis of carbohydrate malabsorption syndrome was made. Preliminary data indicate that the symptoms of patients with IBS improved on a diet that did not include the malabsorbed carbohydrate; we also observed improved depression scores that meant that there was no further need for psychotherapeutical intervention.
In conclusion, we feel that many patients with IBS may have a carbohydrate malabsorption syndrome and may, therefore, develop signs of psychiatric illness. Thus, we suggest that all studies performed on patients with IBS should exclude minor forms of malabsorption syndromes.
Editor,—I would like to thank Dr Ledochowski and colleagues for their interest in our paper, and for presenting evidence of a possible association between fructose or lactose malabsorption and mental depression. They suggest that psychological symptoms in patients with IBS may be due to carbohydrate malabsorption, caused by the interaction between malabsorbed sugars and the amino acid tryptophan. In contrast, we proposed that psychopathology predisposes to the development of IBS. We observed that neurotic traits, life events occurring before an attack of gastroenteritis, and psychological state at the time of the infection, all seemed to predict which patients would develop IBS.
I would not deny that events in the gut may influence state of mind. Research from our department, and others, has indicated that meals rich in fat induce feelings of calmness, tranquility, sleepiness, and friendliness, while carbohydrate rich meals induce tension and hostility, and increase activity in the sympathetic nervous system.1-1 1-2 The bidirectional link between the gut and emotion is so strong that the gut might usefully be regarded as part of the limbic system! However, I remain cynical of the cumbersome and dated tryptophan hypothesis that is so frequently trundled out to explain the effects of food on human mood and behaviour, and would favour a more direct action via afferent nerves.
I have read the paper by Dr Ledochowski and colleagues that was published in Digestive Diseases and Sciences. Of 30 healthy female volunteers, six showed evidence of lactose malabsorption and had higher scores on Beck's Depression Inventory. Analysis of the individual data presented in this paper is less convincing as they are biased by two lactose malabsorbers who scored very highly for depression. The scores of the remaining women were within the range seen in people that absorbed lactose normally. Although the authors concluded that lactose malabsorption induced anxiety and depression, their data could be equally well explained by the effects of psychological tension on gut function.
Psychological tension can accelerate small bowel transit, which in turn can compromise absorption, particularly of foods that are more slowly absorbed. Most of the world's adult population are lactose malabsorbers, but they are not all depressed. Indeed, depression seems to be more common in people that absorb lactose and come from Northern Europe.
Finally, is lactose deficiency or fructose malabsorption truly more common in patients with IBS than in normal subjects? The accumulated data are unconvincing. What seems more likely is that the hypersensitive and hyper-reactive gut of patients with IBS responds more vigorously to an osmotic load, by generating symptoms of diarrhoea, bloating, and pain.